Source/Disclosures
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Healio Interviews

Disclosures: Cantillon reports no relevant financial disclosures. Piccini reports he receives grants for clinical research from Abbott, the American Heart Association, the Association for the Advancement of Medical Instrumentation, Bayer, Boston Scientific and Philips and serves as a consultant to Abbott, Allergan, ARCA Biopharma, Biotronik, Boston Scientific, LivaNova, Medtronic, Milestone, Myokardia, Philips, Sanofi and UpToDate.
August 14, 2020
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Arrhythmia management during COVID-19 incorporates remote monitoring, virtual visits

Source/Disclosures
Source:

Healio Interviews

Disclosures: Cantillon reports no relevant financial disclosures. Piccini reports he receives grants for clinical research from Abbott, the American Heart Association, the Association for the Advancement of Medical Instrumentation, Bayer, Boston Scientific and Philips and serves as a consultant to Abbott, Allergan, ARCA Biopharma, Biotronik, Boston Scientific, LivaNova, Medtronic, Milestone, Myokardia, Philips, Sanofi and UpToDate.
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Since the COVID-19 pandemic started, we have learned about how it affects certain patient populations and how it can lead to complications such as arrhythmias.

In a study published in JAMA in February, 44.4% of patients assessed from Wuhan, China, were treated in the ICU due to complications related to arrhythmias. Arrhythmias may also be aggravated by severe systemic inflammatory conditions associated with COVID-19.

Johnathan Piccini 
Jonathan P. Piccini
Daniel J. Cantillon, MD 
Daniel J. Cantillon

The pandemic has also affected arrhythmia management, with focus shifting to telehealth.

“The pandemic and need to conduct medical care remotely at a distance supercharged the implementation of these technologies,” Jonathan P. Piccini, MD, MHS, FHRS, associate professor of medicine and director of cardiac electrophysiology at Duke University Medical Center, told Healio. “For, example in our [electrophysiology] clinic at Duke, before the pandemic, telehealth visits accounted for far less than 5% of visits. Two weeks into COVID, more than 90% of our clinic visits were telehealth encounters.”

Lingering concerns

Despite the benefits of telehealth such as reduced face-to-face contact, lingering concerns persist regarding whether the technology is sufficient to fill the gap created by the decreased number of in-person visits during the pandemic. The use of telehealth has skyrocketed since the pandemic, which many cardiologists are grateful for because it gives them a tool to provide ongoing care for serious chronic medical issues. It is important to note that telehealth does not replace the need for all in-person health care delivery including essential office visits and medical procedures.

“While the use of virtual visits has helped us partially fill the gap, many cardiologists are growing increasingly concerned [that deferred care] may lead to unchecked progression of disease for some patients,” Daniel J. Cantillon, MD, FACC, FHRS, staff physician and associate section head of cardiac electrophysiology and pacing at the Robert and Suzanne Tomsich Department of Cardiovascular Medicine at Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute and medical director of the central monitoring unit at Cleveland Clinic, told Healio.

Patients with COVID-19 can experience arrhythmias. Moreover, because drugs like hydroxychloroquine may increase the risk for serious abnormalities in heart rhythm including QT interval prolongation, ventricular tachycardia, ventricular fibrillation or death. This led to an FDA safety alert in April, warning health care professionals and patients to avoid the use of hydroxychloroquine outside of hospital or clinical trial settings.

Piccini told Healio his institution has not used a significant amount of hydroxychloroquine to treat COVID-19, as most patients have enrolled in clinical trials of other investigational drugs. In the early phases of the pandemic, Piccini and his colleagues prepared best-practice algorithms for ECG and corrected QT monitoring for hydroxychloroquine.

“Fortunately, we are not aware of any drug-related ventricular arrhythmias within our health system due to the effective use of off-site centralized monitoring for hospitalized patients among other safety measures,” Cantillon said.

In a research letter in the Journal of the American College of Cardiology, mobile outpatient cardiac telemetry improved monitoring of arrhythmia and corrected QT in patients with COVID-19 who were treated with hydroxychloroquine with or without azithromycin.

“Several centers across the country employed this approach,” Piccini said. “This will be another lasting effect of COVID — the increased utilization of ambulatory monitoring for EKG safety assessments. There are a lot of unanswered questions, and we still have a lot to learn.”

Ambulatory telemetry monitoring for patients with arrhythmias is not a novel approach. It was previously used to assess patient response to new antiarrhythmic medication and potential off-target effects.

Although we know more about the effects of hydroxychloroquine in patients with arrhythmias, it turns out that the drug probably does not have a role to play in the treatment of COVID-19.

“There are no randomized data to support the ongoing use of hydroxychloroquine,” Piccini said. “While there were some data early on to suggest it might be helpful, subsequent data from randomized clinical trials have demonstrated no benefit and potential arrhythmic risk.”

Cantillon said, “Ultimately, only appropriately conducted randomized clinical trials will reveal the most promising treatments and allow us to more precisely quantify the risk/benefit ratio for any given therapy.”

The American Heart Association developed a registry to organize and collect data and research and treatment protocols for COVID-19, in addition to risk factors tied to related adverse CV outcomes. The registry, which is powered by its Get With the Guidelines program, will be available to more than 2,400 hospitals.

“This registry allows valuable data to be pooled and shared among participating centers that can then be queried to gain insights into the disease, including how commonly arrhythmias occur and any specific associations with underlying conditions and/or test results, for example,” Cantillon said.

Multidisciplinary collaboration

In the era of COVID-19, multidisciplinary collaboration requires well-organized care pathways and good communication between teams.

“It’s not fundamentally different than pre-pandemic collaboration except for appropriately heightened concerns and perhaps a slim margin for error,” Cantillon said.

Even with a similar approach, cardiologists and health care professionals alike are inspired by the opportunity to work with experts in other areas to care for these patients.

“Multidisciplinary collaboration in the COVID-19 era is a thing of beauty,” Piccini said. “In our health system and in health systems across the country, clinicians from diverse specialties are inspired by the challenge and working together more than ever. The pandemic has also sparked a lot of innovation through collaboration. It has been very gratifying to work with our colleagues in internal medicine, anesthesiology, infectious diseases and surgery to better understand how we can deliver more efficient, coordinated and effective care under rapidly changing circumstances.”

References:

  • American Heart Association Newsroom. New COVID-19 patient data registry will provide insights to care and adverse cardiovascular outcomes. Available at: www.newsroom.heart.org/news/new-covid-19-patient-data-registry-will-provide-insights-to-care-and-adverse-cardiovascular-outcomes. Accessed June 7, 2020.
  • Chang D, et al. J Am Coll Cardiol. 2020;doi:10.1016/j.jacc.2020.04.032.
  • European Society of Cardiology. COVID-19 and Heart Patients (Q&A). Available at: www.escardio.org/Education/COVID-19-and-Cardiology/what-heart-patients-should-know-about-the-coronavirus-covid-19. Accessed June 7, 2020.
  • FDA. FDA cautions against use of hydroxychloroquine or chloroquine for COVID-19 outside of the hospital setting or a clinical trial due to risk of heart rhythm problems. Available at: www.fda.gov/drugs/drug-safety-and-availability/fda-cautions-against-use-hydroxychloroquine-or-chloroquine-covid-19-outside-hospital-setting-or. Accessed June 7, 2020.
  • Wang D, et al. JAMA. 2020;doi:10.1001/jama.2020.1585.

For more information:

Daniel J. Cantillon, MD, FACC, FHRS, can be reached at cantild@ccf.org; Twitter: @djcantillonmd.

Jonathan P. Piccini, MD, MHS, FHRS, can be reached at jonathan.piccini@duke.edu; Twitter: @jonpiccinisr.